GPAtlas🧭 When to suspect
Bacterial meningitis and meningococcal disease are medical emergencies that can kill a previously well person within hours, so the threshold for suspicion must be low and the response immediate. Strongly suspect bacterial meningitis in anyone with the red-flag combination of fever, headache, neck stiffness and an altered level of consciousness or cognition (confusion, delirium or drowsiness). The principal pathogens beyond the neonatal period are Neisseria meningitidis and Streptococcus pneumoniae.
In babies and young children the signs are non-specific – fever, vomiting, poor feeding, lethargy, irritability, a high-pitched or moaning cry, floppiness or a bulging fontanelle – so clinical suspicion must do the work. Above all, do not wait for the rash: the non-blanching petechial or purpuric rash is a late sign of septicaemia, whereas cold hands and feet, severe limb or leg pain, and pale or mottled skin appear earlier.
Keep the threshold lowest in higher-risk groups: infants, adolescents and first-year university students (close living in halls), the unimmunised, and the immunocompromised – asplenia or hyposplenism, sickle cell disease, and complement deficiency (including patients on eculizumab or ravulizumab). The two primary-care skills are simple: recognise early and transfer fast – antibiotics must never delay the ambulance.
| Older children, young people & adults | Babies & young children (signs are non-specific) |
|---|---|
|
• Fever, headache, neck stiffness, photophobia |
• Fever or abnormally low temperature; cold to touch |
|
• Altered consciousness or cognition – confusion, delirium, drowsiness, difficulty waking (the red-flag combination) |
• Poor feeding, vomiting, lethargy or floppiness |
|
• Early septicaemia – severe limb/joint pain, cold hands and feet, pale or mottled skin |
• Irritability, high-pitched or moaning cry, difficult to settle |
|
• Non-blanching rash – petechiae or purpura (lesions > 2 mm); a late and ominous sign |
• Bulging fontanelle; drowsy, difficult to wake or unresponsive |
|
• Rapid deterioration over hours; seizures or focal neurology |
• Rapid deterioration; seizures; cold peripheries or mottling |
Source: NICE NG240
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